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Manipulation Defined

One of the more common complaints that I hear from correctional practitioners (especially new practitioners) is “Manipulative patients are driving me crazy!” To be honest, I ran into a lot of manipulative patients when I worked in the ER, as well. ERs are the epicenter of narcotic drug seeking! But it is true that many of our patients in Corrections are especially skilled in manipulation. They have practiced this skill their whole lives and have become very proficient. Most people, including correctional professionals, are not naturally skilled at dealing with manipulation. This is often not a skill that we have needed before coming to work in a jail or prison. But once there, learning to manage manipulation is an essential skill if you want to be happy in correctional practice. I call the art of dealing with manipulation “Verbal Jiu-Jitsu.” In order to become a skilled practitioner of verbal jiu-jitsu, we must first start with an analysis of what “manipulation” actually is.

Manipulation in a medical encounter occurs when a patient wants something he shouldn’t have and won’t take “No” for an answer. If the patient wants something he should have-no problem! Or If the patient is told “No” and accepts that answer–also no problem!

So manipulation involves these two essential elements:

1. The patient wants something she should not have. This something could be an extra mattress, a special diet, gabapentin, an MRI, a referral off site–anything.

2. The patient does not accept “No” for the answer.

What comes after not accepting “No” for an answer is manipulation. Manipulation is the attempt to coerce the practitioner into changing a “No” into a “Yes.” Manipulation comes in many forms.

1. Exaggeration: “This is the worst pain in the world!” “I can’t stand it any longer!” “I am so much worse now than when I came to prison!” Exaggeration is an attempt to make this a special case, worthy of special consideration compared to other patients. “I know you usually say no but no one else is hurting as much as I am!”

2. Belittling. “Only crappy doctors work in jails. No wonder you can’t understand how to treat my pain syndrome. My outside doctor gave me what I need–oxycontin. Now there was a good and kind doctor! You should be ashamed.” Belittling goes hand-in-hand with splitting.

3. Splitting. This consists of comparing you to someone else who would give the patient what he wants. The other person is commonly an outside practitioner. But splitting is especially effective when the other practitioner is someone within your own facility. “The other doctor who works at this prison gave an extra mattress to my cellie! And he is not in as much pain as I am!”

4. Threatening. This comes in various forms. First is the threat of physical violence. Inmates can get quite skilled at communicating physical threats without saying a word. A particular hard look of tight jaw, narrowed eyes, tense muscles and clenched fists–coming from a muscular guy with facial tattoos–can make anyone feel the hair stand up on the back of the neck, even if there is no way the inmate could/would ever act on the threat. The second type of threats are various forms of complaints. Basically, the inmate is saying, “If you don’t give me what I want, I’ll make your life miserable. I’ll force you to comply with my will.” Complaints may start with written grievances (that you have to spend time and effort to answer), but then can quickly escalate to letters written to the ACLU, formal complaints written to your State Board of Medicine, pro se tort claims and even malpractice lawsuits. Everyone who has worked in corrections for very long has heard these words: “You’ll be hearing from my lawyer!”

5. Fawning. Fawning is, of course, the exact opposite of threatening and belittling. Fawning is more common with female inmates, but males do it as well. “You’re the best doctor I have ever met! I tell all the other girls in the pod how great you are!” Many inmates are exceedingly good at fawning because, again, they have practiced their whole lives. A particularly insidious–and often effective–variation of fawning is flirting and sexual innuendo. “You always smell so good Dr. Smith. What cologne do you use?” I remember one inmate who told me “Dr. Keller, you really know how to wear a suit. I worked at a clothing store, so I know.”

6. Filibustering. Filibustering is being relentless in the demand that you change your mind. Filibustering is done in two distinct ways. Method one is this: “I won’t leave your office until you give me what I want! I will argue with everything you say.” An hour later, the patient is still haranguing you and your clinic schedule (as well as your nerves) are shot. Even more effective is the sequential strategy: “I will be in your clinic every week with the same complaint. Nothing you do (except for what I want) will ever work.” After 3, 5, or 10 visits for the same complaint of “intolerable headaches,” you might finally give in and write the prescription for gabapentin.

7. The straw man victim. The “Straw Man” tactic is where the manipulator charges you with acting against a protected class rather than based on your clinical findings. “You’re only refusing me opioids because of my race/I am transgendered/I am Muslim etc.” (Thank you to Thomas Moll for pointing this one out!)

8. The Champion. A “Champion” is someone who pleads the patient’s case from the outside. The champion can be an attorney, an advocacy group, but most commonly is a family member. Champions use all of the manipulative techniques above, such as exaggeration, splitting and incessant filibustering. Since champions are not incarcerated, they have access to many people who inmates themselves cannot reach, such as the sheriff, the newspaper, and even the state governor.

9. Self-harm. Self-harmers are patients who deliberately harm themselves to force you to do something they want. Examples of self-harmers include patients who cut themselves (“cutters”), “inserters” (patients who insert foreign bodies under the skin, into the penis or anywhere it does not belong) and diabetics who try to induce severe hypoglycemic or hyperglycemic events in themselves. Self-harmers are often particularly hard to deal with.

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22 thoughts on “Manipulation Defined”

“Manipulation” is a dangerous term to use, especially if it’s put in the medical record. There just might be a time the term is used and it turns out to have been an authentic complaint and the condition missed with an unfavorable result. If used, the term should only be applied after a through evaluation of all complaints. Why not just stay away from it all thogether. It dosen’t accomplish anything other a manifestation of one’s frustration and ego. Use a phrase like “Patient throughtly evaluated with appropriate testing and no verifiable disease condition can be found at this time. Patient was advised to return if symptoms increase or persist.”

I absolutely 100% agree, Charles! That is one of the cardinal points of verbal jiu jitsu–never to use the word “manipulating” in one’s documentation. Also, never use the word “faking” or “malingering” or any other disparaging and dismissive term.
I can’t think of an alternative word, however, to facilitate the discussion of “Dysfunctional ways in which patients will try to make a practitioner order something that the patient should not have.” What word do we use to describe this phenomenon? I can’t think of anything else except “manipulation”–and that is the word that is used in mental health circles.

In my experience, the term “instrumental behavior” has been used to indicate manipulative behaviors. For example, Under the heading of Clinical Rationale (for discharge from suicide observation): Pt demonstrated instrumental behavior in order to effect change on housing/status.

Definition
Instrumental behavior is action performed to reach a goal, such as to obtain a food item, achieve some other kind of reward, or remove a punishment; the behavior causes the desired outcome.

You make an excellent point about using the technique of the broken record. You simple restate your objective findings, recommendation ( usually education that the Detainee rejects) and don’t cave. You take the high road and limit the visit time. Good strategy.

You make an excellent point about using the technique of the broken record. You simple restate your objective findings, recommendation ( usually education that the Detainee rejects) and don’t cave. You take the high road and limit the visit time. Good strategy. I fully support not using questionable terms like manipulation and malingering because they are diagnoses of exclusion requiring exhaustive and expensive tests and procedures that are not necessary to negate a Detainee’s claim. Watch the words and apply consistent standards of only providing medically necessary care as supported by your assessment.

While it is true that manipulative behavior is not uniquely encountered in corrections (as it is a common occurrence in medical practice outside correctional facilities, as well), patients deprived of their liberty become particularly skilled in developing those behaviors that are most conducive to manipulation. As such, to avoid this subject (especially in relation to medical practice in corrections) just because it does not sit well with evidence-based medicine practices seems senseless. If clinicians elsewhere would work in close proximity to where their patients lived, having the added possibility to closely monitor the behavior and lifestyle of patients outside the medical office, then their perspective on how they are affected by patients’ manipulative strategies would change.

Once a manipulative behavior is detected, the clinician is called to make an informed decision about the request of the patient. Two particular situations are important to be remembered in this respect: (1.) the request may not always be clear or straightforward, while the duplicitous behavior is clearly present, and (2.) sometimes, what appears as simulation may simply be an artifact – such as an effect of somatization.

Manipulation, defined as a purpose-oriented demeanor (the patient always trying to get something, against or aside from the medical advice) may also not be quite evident at all times – sometimes all that the patient strives for is just attention or human touch. However, most of the time we can frame manipulation in the medical clinic as being an attempt of the patient to impose his wish over a professional’s decision.

Influence, persuasion, manipulation and coercion are all terms used to express how, in various degrees and from different perspectives (intent, scope/purpose/outcome) one’s knowledge and emotions are used to construct and develop a working behavioral pattern that serves the individual in question in his/her relation to other people. The fact that such a behavior is not “natural” or disinterested, but intentional and constructed (desired and well thought-out) in view of a more-or-less defined purpose prepared the field for manipulation to occur. The manipulated person is left with a feeling of dissatisfaction for having done something against his own will. Robert Cialdini’s work in this field of human interactions is a great ressource.

More often than not, in corrections manipulation occurs with an apparent purpose (i.e., what the patient wants to obtain from the medical team), but the real motive behind the display of each eliciting/soliciting behavior is much less obvious – the sheer joy of having succeeded yet again, against the direst odds, in breaching the rules. In jails and prisons worldwide this is a matter of gaining stature, a way of proving oneself that he is still in charge of his own life and not being “had” by the system entirely.

It is also important to remember that perhaps the medical clinic of a facility is perhaps the least affected sector of the prison by the manipulative behavior of inmates. One’s own health is only the last currency to be used in relation to the administration, as inmates generally do not want to antagonize the medical staff, which they recognize as being there to help them when needed. This is why I believe that when such actions of manipulating the medical staff multiply in a prison, it may be an indicator of how other needs of prisoners are not met, and a conversion strategy happens as a result – a form of “medicalization” of unmet needs.

I am so thankful to find this information sharing. For the past 2 days, I provided nursing care and medication administration to an inpatient on a medical-surgical unit. Our facility provides psychiatric services on campus. When required, patients are admitted to the medical unit for stabilization before transferring to the psychiatric unit. This patient was admitted with a blood alcohol level over 300 and tachycardia to 130s. When I assumed his care, he had already been through the alcohol withdrawal process for 3-4 days.

On initial morning rounds, he told me “it is time for my shot. My doctor says I can have the shot every 2 hours”‘
The shot is valium 5 mg IV. He also told me how he wanted to take his meds at bedtime. His other meds included Librium 100mg q 6 hours that tapered to 50mg q 6 hours, oral vitamins including thiamine, folic acid, multivitamin B&C and ativan 3 mg q 4 hours as needed. The comment on the IV valium said to only administer if the ativan was not effective.

I started Monday am by giving him the ativan 3mg with other oral meds, mostly vitamins. I kept on schedule with the 100mg librium taper. When I took the 100mg librium, he asked for “a shot”. I said I could give the ativan “after lunch”, meaning 1pm. He asked if he drank his liquid supplement, Ensure, if that counted as “lunch”. I said it counted as nutrition. As one of my treatment options, I gave 4mg zofran IV “before lunch” with the librium. As I gave the zofran for nausea, he drank the Ensure saying he had his lunch so he can have the ativan which would be an hour early.

Over the weekend, someone provided him with a printed med sheet, so he kept referring to it. I said I was using the computer for med administration, not his printed med list

On Monday, I kept on schedule with librium 100mg q 6hours and ativan 3mg q 4 hours. He used every tactic listed above telling me he was doing what the doctor prescribed. I was the “worst nurse”, then I was the “best nurse”. At one point he jumped on the elevator with the pharmacy tech to follow her to the pharmacy to inquire about his meds. Tuesday afternoon he packed his belongings to leave saying he was going to rehab and had to go home and take care of business.

By Tuesday afternoon, he had everything he requested: a new room, where he thought he would have new staff, new iv site for “the shot” so he could get his iv valium along with po hydroxyzine, and a referral to the behavioral health unit.

He refused to go to inpatient treatment, anticipating a screening for outpatient care. I kept trying to tell him that taking more meds and iv meds may derail his plans for outpatient care. Though he was insistent for the shot for 2 days. When behavioral health was consulted, they said they needed a CIWA score less than 12 when he had been off benzos for 6 hours. On admission, he had CIWA 22 and ETOH > 3oo. Several days later, I assessed CIWA 15 after he had ativan 6 hours prior though he had the scheduled librium 50mg at 3 hours after ativan and 3 hours before CIWA score.

He got in touch with family, who then started calling the unit so then they paged me to the phone!

According to the social worker notes, he also has legal and housing issues and debt. All of the trained staff are trying to help with these issues and offer resources. However, he is very insistent on his desires and uses jiu-jitsu effectively to accomplish his goals.

At the end of 2 days, the patient had used verbal jiu-jitsu effectively to receive everything he wanted. I was in trouble with management since he got on the elevator with the pharmacy tech and his time-consuming jiu-jitsu tactics got me behind on other tasks with very ill patients.

I realize these posts are for correctional, jail, medicine. They are also very informative and helpful to me who provide care for patients in these situations and on these meds.

Any information about behaviors, medications, resources and staff support are appreciated!

Fantastic analysis of what providers are up against daily. Our best defense is the “toolbox” which we bring to work daily, those abilities we have honed over the years thru training and practice, which requires daily investment. When providers are put in position to employ a “toolbox” full of the fundamentals of medicine, problems such as Utilization Management, malpractice negligence, staff retention and patient complaints are minimized as well as healthcare utilization by patients. We need our patients to trust in our care again. When the word in prison gets out that Dr X cares, inmates protect Dr X’s practice quickly and efficiently, all the while reading Scripture to Dr X. Looking forward to much more Jeff, thank you.

With respect, your post on manipulation misses one important and real cause of manipulative behavior: the inmate who is not being properly managed and has no other recourse than to engage in the behaviors you are implicitly assigning a pejorative character. There is no doubt that medicine as practiced in correctional facilities is not of the same quality as care available to the general public. This is a result of myriad issues, none of which can be solved by any one practitioner with even the best intentions. Yet it is important to remember this when confronting a patient who is advocating for their care in the only means they have available – namely using the methods you have listed above. While there is no doubt that practitioners in correctional facility will be faced with a many inmates who are in fact purposefully manipulating them in a with malfeasant intent, this post is no an honest evaluation of the situation with addressing the likelihood some of the inmates displaying the behaviors you describe above are doing so because of deficiencies in the quality of care you are willing or able to provide in the correctional setting.

Thank you for the comment, David. I agree that it is important for correctional practitioners to be humble and always keep in mind that we might be wrong–not only about this but also about other things, like diagnoses, interpreting tests, etc. Having said that, I think that most cases of manipulative behavior do NOT fall into this category. I disagree with your statement that “medicine as practiced in correctional facilities is not of the same quality as care available to the general public.” That certainly is not true in my facilities, as a general rule. In fact, one of the biggest problems that many correctional facilities–both jails and prisons–have on an ongoing basis is transitioning patients out of the facility back into the community, where they have no insurance, no way to pay for ongoing medical care and so no easy way to continue medical therapies begun in the jail. I’m sure that you have specific cases in mind where you think the correctional medical care was deficient and we could debate the merit of these cases, but the blanket assertion about all medical care in all correctional facilities is deficient is (IMO) not true.

blanket assertion about all medical care in all correctional facilities is deficient is (IMO) not true.:: I agree with your point. I would like to add Mental health and dental care to this statement.

At the community level, Quality of care is neither uniform nor guaranteed . In addition one may need to wait long time for tx, to deal with referral denials , post treatment dollar issues etc . Accessibility and the speed at which the healthcare is delivered is better inside than outside. ( which itself can be a double edged sword at times)
Today’s topic of this unhealthy behavior is seen both sides of the fence. I think providers are quick to pick up this style and react when providing care inside the fence.

Thanks you for your opinion David , and I take issues with the “The straw man victim”
mentioning people that are not like the majority and are an “easy hit”
why the author did not say” gay”, “black ” “addict” or” prostitute” etc?
because that is not PC !
but is ok to mention others that right now are in fashion to be” abused de jour”

Another manipulative tactic is what I call the straw-man victim where the manipulator charges you with acting against a protected class rather than based on your clinical findings. “You’re only refusing me opioids because I am transgendered/of colour/of a different faith system/etc.” As with most manipulators, the broken record reply works best.

Also, a team approach is important. Especially with the opioid prescriptions but also with the unusual item request. This way the provider can say that he sent the request to committee but it was determined that medical necessity was not indicated. Medical departments should also get out of the business of being the approver of unique privileges as much as possible. We should not be the ones to provide documentation for patients to get snacks, special footwear, and the myriad other things that inmates ask for. The more privileges we allow ourselves to be the arbiter of, the more we set ourselves up for unnecessary conflicts and grievances.

Good point re putting patients’ requests for change before a committee. I work as the medical officer at an addiction service, and we discuss all but the most trivial requests as a team, formulate a response that is rational and humane, and ensure that we all give the same answer in case (as often happens) we are asked separately for an answer by the patient. One of the best things about this technique is that you don’t have to give an immediate answer to a request which you later need to reverse, thereby damaging any trust the patient has in you.

Hello. During my second year of college for Criminal Justice, an addiction to opiates caused me to be arrested and sent to prison for Doctor Shopping. I read and enjoy your blog from more than one perspective. I was pregnant and on methadone when I arrived to prison and a few months later, I felt like I was experiencing withdrawals and needed an increase. I was told that nobody, under any circumstances, was granted increases in methadone while pregnant at this prison. I compiled several articles regarding the need for small increases in the last trimester if Mom is feeling any withdrawal symptoms and I sent them along with a second request. I was then written up and told that I was trying to manipulate for the purpose of attempting to be intoxicated. What is your take on that? Do you see that as such?

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Jeffrey Keller

About

Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of emergency medicine practice experience before moving full time into his “true calling” of Correctional Medicine. He is the Medical Director of Badger Medical, which provides medical services to several jails and juvenile facilities in Idaho. Dr. Keller is available for consultation on any aspect of Correctional Medicine, including legal cases, program development, and system analysis.

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